{{$sRegFormJavaScript}}

<h3>{{$title}}</h3>
	<table border=0 cellspacing=0 cellpadding=0>
	<tbody>

		{{if $sInterconsultanteInput}}
		<tr>
			<td class="reg_item">
			{{$LDInterconsultante}}
			</td>
			<td class="reg_input">
			{{$sInterconsultanteInput}}
			</td>
		</tr>
		{{/if}}

		{{if $sEstablecimientoInput}}
		<tr>
			<td class="reg_item">
			{{$LDEstablecimiento}}
			</td>
			<td class="reg_input">
			{{$sEstablecimientoInput}}
			</td>
		</tr>
		{{/if}}

		{{if $sEpecialidadRadio}}
		<tr>
			<td class="reg_item">
			{{$LDEspecialidad}}
			</td>
			<td class="reg_input">
			{{$sEpecialidadRadio}}
			</td>
		</tr>
		{{/if}}

		{{if $sPacienteInput}}
		<tr>
			<td class="reg_item">
			{{$LDPaciente}}
			</td>
			<td class="reg_input">
			{{$sPacienteInput}}
			</td>
		</tr>
		{{/if}}

		{{if $sNombreCompletoInput}}
		<tr>
			<td class="reg_item">
			{{$LDNombreCompleto}}
			</td>
			<td class="reg_input">
			{{$sNombreCompletoInput}}
			</td>
		</tr>
		{{/if}}
		
		{{if $sFemInput || $sMasInput }}
		<tr>
			<td class="reg_item">
				{{$LDSexo}}
			</td>
			<td class="reg_input">
				{{$sFemInput}}{{$LDFem}}
				{{$sMasInput}}{{$LDMas}}
			</td>
		</tr>
		{{/if}}
			
		<tr>
			<td><h3>{{$LDInterData}}</h3></td>
			<td></td>
		</tr>
		<tr>
			<td class="reg_item">
				{{$LDFecha}}
			</td>
			<td class="reg_input">
				{{$sFechaInput}}
			</td>
		</tr>
		<tr>
			<td class="reg_item">
				{{$LDMotivo}}
			</td>
			<td class="reg_input">
				{{$sMotivoText}}
			</td>
		</tr>
		<tr>
			<td class="reg_input">
			</td>
			<td class="reg_input">
				{{$LDListarIC}}
			</td>
		</tr>
	</tbody>
	</table>
<form method="post" action="{{$action}}" name="form" ENCTYPE="multipart/form-data" onSubmit="return chkform(this)">
<h3>{{$LDAsignarCons}}</h3>
	<table>
		<tr>
			<td class="reg_item">
				{{$LDMedDispo}}
			</td>
			<td class="reg_input">
				{{$LDMedDispoCombo}}
			</td>
		</tr>
	</table>

	{{$pbSubmit}}

</form>